417 lines
29 KiB
Markdown
417 lines
29 KiB
Markdown
---
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title: "Ductus Diverticulum"
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docid: "9b1101bc-83a2-445c-aef5-53d633e5bec0"
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authors:
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- key: "a354e6da-2757-40e8-b7ff-5e6fb6413ff6"
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value: "Sachin S. Saboo, MD, FRCR, FSCMR"
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- key: "770e1d77-2287-436e-910b-48232afc7842"
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value: "Prabhakar Rajiah, MBBS, MD, FACR, FRCR, FACC, FAHA, FSCCT"
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breadcrumbs:
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-
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name: "Cardiac"
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slug: "cardiac"
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treeNodeId: "fa90100b-619c-430e-8074-b5b9789bab39"
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-
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name: "Diagnosis"
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slug: "diagnosis"
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treeNodeId: "5c92cf4f-e9d5-4059-9c13-22255c51c121"
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-
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name: "Aorta"
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slug: "aorta"
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treeNodeId: "4d206a6b-1a82-467c-9199-0df25ab749d7"
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-
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name: "Ductus Diverticulum"
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slug: "ductus-diverticulum"
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treeNodeId: null
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category: "Cardiac"
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documentVersionId: "f74b3068-f527-45c0-b021-5088d30db81f"
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imageCount: 19
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lastUpdated: "01/24/25"
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pageDescription: "Ductus Diverticulum"
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pageKeywords: "Cardiac, Diagnosis, Aorta, Ductus Diverticulum"
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pageTitle: "Ductus Diverticulum | STATdx"
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enhancedTitle: "Ductus Diverticulum"
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type: "DX"
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references: true
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breadcrumbs:
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- "Cardiac"
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- "Diagnosis"
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- "Aorta"
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- "Ductus Diverticulum"
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---
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# KEY FACTS
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- ## Terminology
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- Smooth focal bulge along anteromedial aspect of aortic isthmus at site of obliterated ductus arteriosus
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- ## Imaging
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- Chest radiography
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- Frontal: Opacity in aortopulmonary window
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- Lateral: Small, bump-like opacity at distal transverse aortic arch
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- Contrast-enhanced CTA or MRA
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- Differentiate between typical and atypical appearances
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- Evaluate for aneurysmal dilatation
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- Differentiate from traumatic pseudoaneurysm
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- Ductus diverticulum aneurysm
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- Saccular dilatation along anterior inferior margin of aortic isthmus
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- Superior margin of aneurysm extends to left subclavian artery
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- Differentiate from traumatic pseudoaneurysm
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- Presence of smooth, uninterrupted margins of diverticulum
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- No dissection flap
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- Absence of mediastinal or periaortic hematoma
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- ## Top Differential Diagnoses
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- Aortic isthmus (traumatic) pseudoaneurysm
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- Aortic ulcerated atherosclerotic plaque
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- Aortic aneurysm
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- Kommerell diverticulum
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- Patent ductus arteriosus
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- ## Clinical Issues
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- Typically incidental finding
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- Most patients are asymptomatic
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- Aneurysmal dilatation of ductus diverticulum necessitates intervention if > 3 cm
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- Endovascular stent graft or conventional open surgical repair
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# TERMINOLOGY
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- ## Synonyms
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- Ductus bulge; ductus bump
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- ## Definitions
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- Smooth focal bulge along anteromedial aspect of aortic isthmus at site of obliterated ductus arteriosus/ligamentum arteriosum
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# IMAGING
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- ## General Features
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- ### Best diagnostic clue
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- Well-defined, smooth, broad-based outpouching from anteromedial aspect/lesser curvature of aortic isthmus with obtuse angle with aorta
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- Mediastinum and aorta are otherwise unremarkable
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- ### Location
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- Along anteromedial aspect of aortic isthmus
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- ### Size
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- Usually small bulge
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- May increase aortic diameter by average of 4.3 mm
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- Unusually enlarged ductus referred to as aneurysm
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- Aneurysmal dilatation of ductus diverticulum > 3 cm needs surgical intervention
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- ### Morphology
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- Smooth bulging of aortic side of ductus arteriosus
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- ## Imaging Recommendations
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- ### Best imaging tool
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- 3D CT or MR angiography (CTA, MRA)
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- ### Protocol advice
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- Contrast-enhanced CTA
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- Sagittal oblique thin-slice (≤ 1 mm) reconstructed images
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- Essential to identify and assess relationship of ductus with pulmonary artery (PA), aortic arch, and subclavian artery (SCA)
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- Visualize smooth shoulders of ductus diverticulum
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- Volume-rendering technique (VRT)
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- To convey 3D anatomic relationships with adjacent vessels and structures than MIP
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- Cinematic-rendered visualization
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- 3D visualization methodology with increased surface detail of anatomy and more realistic shadowing effects than can be achieved with VRT
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- Noncontrast 3D slap MRA or contrast-enhanced MRA
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- Sagittal oblique and coronal thin reconstructed MIP
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- Consider sagittal oblique and axial black-blood imaging
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- ## Radiographic Findings
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- Frontal chest radiograph
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- May manifest as opacity in aortopulmonary window
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- Lateral chest radiograph
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- Small, bump-like opacity at distal arch/isthmus
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- ## CT Findings
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- General
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- Best visualized on sagittal oblique reconstructed images
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- May be difficult to identify ductus diverticulum on axial due to partial volumining from oblique orientation
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- Typical appearance
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- Broad-based, contrast-filled outpouching at anteromedial aortic isthmus extending blindly inferiorly toward main PA
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- Best clue: Smooth, uninterrupted margins; gently sloping, symmetric shoulders; obtuse angles with aorta at its superior and inferior margins
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- Increase in aortic lumen ≤ 1 cm
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- Smaller vertical height diameter (5.5 mm vs. 11.2 mm) and broader base (14.9 mm vs. 8.8 mm) compared with traumatic pseudoaneurysm
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- Atypical appearance
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- Steep and asymmetric sloping
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- Acute angles at superior margin with loss of gentle superior angle
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- Ductus may fold back against aorta and result in pseudointimal flap
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- Ductus diverticulum aneurysm
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- Saccular dilatation along inferior margin of aortic isthmus opposite origin of left SCA
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- Superior margin of aneurysm extends to left SCA
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- Axial CTA images may show typical 3-star sign at aortopulmonary window
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- Proximal arch, descending aorta, and saccular aneurysm of diverticulum appear as hook-shaped structure
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- Detection of small pedicle/fibrotic portion of ductus linking aneurysm to PA differentiate ductal aneurysm from aneurysm of aorta
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- Partial thrombosis of ductus diverticulum aneurysm can be FDG avid on 18F-FDG PET/CT due to inflammation of wall
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- Differentiate from traumatic pseudoaneurysm
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- Presence of smooth, uninterrupted margins with smaller vertical height, obtuse angle with aorta in ductus diverticulum
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- Absence of dissection flap
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- Absence of mediastinal or periaortic hematoma
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- ## MR Findings
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- ### MRA
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- MRA and postcontrast GRE images help exclude pseudoaneurysm from atypical ductus diverticulum
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- Findings similar to those on CTA
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- Smooth outpouching at anteromedial aspect of aortic isthmus
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- No dissection flap
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- ## Angiographic Findings
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- Contrast-filled, well-defined smooth outpouching arising from anterior inferior margin of aortic isthmus
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- No dissection flap
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- Pseudodissection flap may be seen with diverticulum that is folded over
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- Contrast retention is rarely seen in atypical ductus diverticulum on delayed angiogram views
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- Typically occurs in traumatic pseudoaneurysm
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- Aneurysm of ductus diverticulum
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- Saccular dilatation along anterior inferior margin of aortic isthmus
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- Superior margin of aneurysm extends to left SCA
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# DIFFERENTIAL DIAGNOSIS
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- ## Pseudoaneurysm at Aortic Isthmus (Pseudoductus)
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- Due to partial or complete aortic transection
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- Contrast-filled, irregular outpouching
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- Varying size/shape; relatively longer vertical diameter
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- Due to focal disruption of intima and media
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- Narrow base and acute angles at cranial and caudal ends
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- Intimal flap in underlying aorta
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- Mediastinal or periaortic hematoma
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- May compress aortic lumen
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- Delayed clearance of contrast on angiography
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- ## Ulcerated Atherosclerotic Plaque at Aortic Isthmus
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- Contrast-filled, irregular outpouching
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- Commonly associated with mural thickening and Ca⁺⁺
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- Solitary or multifocal
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- Typically seen in older adult patients
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- [Aortic Aneurysm](/document/aortic-aneurysm/54f93fcd-d960-4770-8d02-1923adb2c01c)
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- Typically atherosclerotic in etiology, seen in older adults
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- Not usually localized to region of ductus
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- Saccular aneurysm involves anterolateral aorta
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- Absence of small fibrotic pedicle seen with ductal aneurysm
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- ## Kommerell Diverticulum
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- Dilatation/aneurysm of aberrant right/ left SCA origin
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- May be associated with right aortic arch and vascular ring
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- [Patent Ductus Arteriosus](/document/patent-ductus-arteriosus/5ba3261d-bd13-4542-92ec-5db5274e2050)
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- Beyond 3 months after birth
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- Left-to-right shunt via funnel, tubular or window-type connection
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# PATHOLOGY
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- ## General Features
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- ### Etiology
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- In developing fetus, ductus arteriosus connects PA to descending aorta for right-to-left shunt
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- Allows most of blood from right ventricle to bypass fetal lungs in utero
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- Normally closes after birth, functionally within 24 to 48 hours and anatomically in 1 week to 2 months
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- Ductus diverticulum is embryologic remnant of infundibular part of ductus arteriosus or remnant of right dorsal aortic root
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- Located at transition from aortic arch to descending aorta called aortic isthmus
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- Aortic isthmus is slightly constricted part of proximal descending thoracic aorta immediately distal to left SCA at attachment point of ductus arteriosus
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- Aortic spindle is small, circumferential bulge just below aortic isthmus
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- ### Associated abnormalities
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- Aneurysm of ductus diverticulum
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- Patent ductus arteriosus
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- Ductus diverticulum common (21%) in acute type B aortic dissection (TBAD)
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- Primary entry tears in acute TBAD located at ductus diverticulum orifice
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- ## Staging, Grading, & Classification
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- Classification based on appearance
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- Typical, atypical
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- Classification of aortic isthmus
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- Type I: Concave contour of aortic isthmus with parallel walls and uniform diameter; most common type
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- Type II: Mild straightening or convexity of aortic isthmus without discrete bulge
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- Type III: Ductus diverticulum: Discrete focal bulge of aortic isthmus least common type (8-26%)
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- ## Microscopic Features
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- Remnant of infundibular part of ductus arteriosus
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# CLINICAL ISSUES
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- ## Presentation
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- ### Most common signs/symptoms
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- Asymptomatic
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- Typically incidental finding
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- ### Other signs/symptoms
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- Aneurysmal dilatation
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- Embolic stroke, compression of local thoracic structures producing cough, hoarseness, dyspnea, chest pain, neck pain, dysphagia
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- Rupture may lead to hemodynamic instability
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- ## Demographics
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- Age: More common in children than in adults
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- Dissection patients with ductus diverticulum were relatively younger than TBAD alone
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- Sex: M = F
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- Epidemiology
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- 33% of infants
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- 9-26% of adults in angiography study
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- ## Natural History & Prognosis
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- Diverticulum usually shrinks over time
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- Small, residual bump at isthmus
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- Rarely ductus aneurysm formation in
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- Hypertensive and older adults with atherosclerotic aorta
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- Behçet disease, Marfan and Ehlers-Danlos syndromes
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- Following surgical closure of patent ductus arteriosus
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- Rupture, dissection, thromboembolism, phrenic nerve compression, and infection of aneurysm may occur
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- Ligamentum arteriosum (fibrous band) develops from obliteration of ductus arteriosus at aortic isthmus and can develop linear calcification
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- ## Treatment
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- Usually no treatment required
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- Aneurysmal dilatation of ductus diverticulum → intervention if > 3 cm, or enlarging or symptomatic
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- Endovascular stent graft repair
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- Conventional open surgical repair
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- Endovascular coil embolization if standard thoracic endovascular aortic repair (TEVAR) method is unsuccessful
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# DIAGNOSTIC CHECKLIST
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- ## Image Interpretation Pearls
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- Best imaging tool: 3D CT or MR angiography (CTA, MRA)
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- Best visualized on sagittal oblique reformatted CTA/MRA/angiography images
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- Differentiate from traumatic pseudoaneurysm
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- Smooth, uninterrupted margins, broad base with aorta, smaller vertical height
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- Absence of dissection flap
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- Absence of mediastinal or periaortic hematoma
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a73cc84a-87fa-4d1c-aa19-e7d897f011c2
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## References
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# Selected References
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1. [Chen D et al: Association of ductus diverticulum and acute type B aortic dissection. Acad Radiol. 30(11):2541-7, 2023](http://www.ncbi.nlm.nih.gov/pubmed/?term=36754645%5Bpmid%5D)
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1. [Celik E et al: The aortic ductus diverticulum-innocent bystander or potential source of thromboembolic stroke? J Comput Assist Tomogr. 46(3):392-6, 2022](http://www.ncbi.nlm.nih.gov/pubmed/?term=35575652%5Bpmid%5D)
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1. [Buechner D et al: Successful endovascular coil embolization of large pseudoaneurysm of ductus arteriosus diverticulum. CVIR Endovasc. 2(1):12, 2019](http://www.ncbi.nlm.nih.gov/pubmed/?term=32026144%5Bpmid%5D)
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1. [Rowe SP et al: MDCT of ductus diverticulum: 3D cinematic rendering to enhance understanding of anatomic configuration and avoid misinterpretation as traumatic aortic injury. Emerg Radiol. 25(2):209-13, 2018](http://www.ncbi.nlm.nih.gov/pubmed/?term=29327106%5Bpmid%5D)
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1. [Thampy R et al: Thrombosed aneurysm of the ductus diverticulum mimicking malignancy on 18F-FDG PET/CT. BMJ Case Rep. 11(1), 2018](http://www.ncbi.nlm.nih.gov/pubmed/?term=30598473%5Bpmid%5D)
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1. [Nagpal P et al: Advances in imaging and management trends of traumatic aortic injuries. Cardiovasc Intervent Radiol. 40(5):643-54, 2017](http://www.ncbi.nlm.nih.gov/pubmed/?term=28078377%5Bpmid%5D)
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1. [Hyung Ann J et al: Morphologic evaluation of ductus diverticulum using multi - detector computed tomography: comparison with traumatic pseudoaneurysm of the aortic isthmus. Iran J Radiol. 13(4):e38016, 2016](http://www.ncbi.nlm.nih.gov/pubmed/?term=27895881%5Bpmid%5D)
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1. [Modi A et al: Dissection from ductus diverticulum presenting as type A intramural hematoma. Asian Cardiovasc Thorac Ann. 22(1):107, 2014](http://www.ncbi.nlm.nih.gov/pubmed/?term=24585659%5Bpmid%5D)
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1. [Agarwal PP et al: Multidetector CT of thoracic aortic aneurysms. Radiographics. 29(2):537-52, 2009](http://www.ncbi.nlm.nih.gov/pubmed/?term=19325064%5Bpmid%5D)
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1. [Vogler T et al: [Diverticulum of the ductus arteriosus. Cause of traumatic aortic ruptures?.] Chirurg. 78(1):47-51, 2007](http://www.ncbi.nlm.nih.gov/pubmed/?term=17151844%5Bpmid%5D)
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1. [Saito N et al: Successful endovascular repair of an aneurysm of the ductus diverticulum with a branched stent graft: case report and review of literature. J Vasc Surg. 40(6):1228-33, 2004](http://www.ncbi.nlm.nih.gov/pubmed/?term=15622379%5Bpmid%5D)
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1. [Gotway MB et al: Thoracic aorta imaging with multisclice CT. Radiol Clin North Am. 41(3):521-43, 2003](http://www.ncbi.nlm.nih.gov/pubmed/?term=12797604%5Bpmid%5D)
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1. [Sugimoto T et al: Aneurysm of the ductus diverticulum in adults: the diagnostic value of three-dimensional computed tomographic scanning. Jpn J Thorac Cardiovasc Surg. 51(10):524-7, 2003](http://www.ncbi.nlm.nih.gov/pubmed/?term=14621015%5Bpmid%5D)
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1. [Batra P et al: Pitfalls in the diagnosis of thoracic aortic dissection at CT angiography. Radiographics. 20(2):309-20, 2000](http://www.ncbi.nlm.nih.gov/pubmed/?term=10715333%5Bpmid%5D)
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1. [Ferrera PC et al: Ductus diverticulum interpreted as traumatic aortic injury. Am J Emerg Med. 15(4):371-2, 1997](http://www.ncbi.nlm.nih.gov/pubmed/?term=9217528%5Bpmid%5D)
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1. [Fisher RG et al: "Lumps" and "bumps" that mimic acute aortic and brachiocephalic vessel injury. Radiographics. 17(4):825-34, 1997](http://www.ncbi.nlm.nih.gov/pubmed/?term=9225385%5Bpmid%5D)
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1. [Oxorn D et al: The ductus diverticulum: false-positive angiographic diagnosis of traumatic aortic disruption. J Cardiothorac Vasc Anesth. 11(1):86-8, 1997](http://www.ncbi.nlm.nih.gov/pubmed/?term=9058228%5Bpmid%5D)
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1. [Grollman JH: The aortic diverticulum: a remnant of the partially involuted dorsal aortic root. Cardiovasc Intervent Radiol. 12(1):14-7, 1989](http://www.ncbi.nlm.nih.gov/pubmed/?term=2496921%5Bpmid%5D)
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1. [Morse SS et al: Traumatic aortic rupture: false-positive aortographic diagnosis due to atypical ductus diverticulum. AJR Am J Roentgenol. 150(4):793-6, 1988](http://www.ncbi.nlm.nih.gov/pubmed/?term=3258092%5Bpmid%5D)
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1. [Goodman PC et al: Angiographic evaluation of the ductus diverticulum. Cardiovasc Intervent Radiol. 5(1):1-4, 1982](http://www.ncbi.nlm.nih.gov/pubmed/?term=6805955%5Bpmid%5D)
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## Images
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### Selected Images
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*Graphic demonstrates normal anatomy of the great vessels and the presence of a ductus diverticulum (DD) <img src='img/arrows/WO.png'/>, part of the remnant of the embryologic ductus arteriosus that connected the pulmonary arteries and the aorta in utero. The rest of the ductus becomes the ligamentum arteriosum <img src='img/arrows/WS.png'/>.*
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*Graphic demonstrates normal anatomy of the great vessels and the presence of a ductus diverticulum (DD) <img src='img/arrows/WO.png'/>, part of the remnant of the embryologic ductus arteriosus that connected the pulmonary arteries and the aorta in utero. The rest of the ductus becomes the ligamentum arteriosum <img src='img/arrows/WS.png'/>.*
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*Axial (left) and sagittal oblique (right) images in a 85-year-old woman show a broad-based DD <img src='img/arrows/CO.png'/> with rim calcification. This is a common finding in patients of all ages and should not be confused with pathology.*
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*Axial CECT shows a typical DD <img src='img/arrows/WS.png'/> arising from the very proximal portion of the descending thoracic aorta (DTA), just distal to the left subclavian artery.*
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*Coronal reformatted CECT demonstrates a typical DD <img src='img/arrows/WC.png'/>. The close proximity of the DD to the pulmonary trunk reflects its underlying etiology as the remnant of the infundibular part of the ductus arteriosus that connected the pulmonary artery to the aortic arch in utero.*
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*CECT though the inferior aspect of the proximal DTA shows a partially thrombosed 4.8-cm ductal aneurysm (DA) <img src='img/arrows/CS.png'/> with compression of the left pulmonary artery <img src='img/arrows/BS.png'/> on coronal oblique image.*
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*Axial CECT (left) shows spontaneous contained rupture of a 6 x 4 cm DA <img src='img/arrows/CO.png'/> with surrounding hematoma. Sagittal oblique CECT (right) shows the large DA <img src='img/arrows/CC.png'/> with small calcifications <img src='img/arrows/CS.png'/> along its edge, which are common. There is no aortic atherosclerotic disease. (Courtesy S. Kligerman, MD.)*
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*Axial black-blood MR of an asymptomatic patient demonstrates focal outpouching <img src='img/arrows/WS.png'/> of the anterior wall of aortic isthmus.*
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*Sagittal black-blood MR in the same patient shows smooth outpouching <img src='img/arrows/WO.png'/> from the anteromedial wall of aortic isthmus. These findings are classic for a DD. The absence of an intimal flap and the lack of mediastinal or periaortic hematoma essentially exclude the possibility of a traumatic pseudoaneurysm.*
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*Axial CECT demonstrates focal outpouching <img src='img/arrows/WS.png'/> from the anterior wall of the aortic isthmus, consistent with a typical DD.*
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*Axial CECT shows a partially thrombosed DD aneurysm <img src='img/arrows/WS.png'/>. Although most patients are asymptomatic and require no treatment, the presence of aneurysmal dilatation > 3 cm necessitates endovascular stent graft or open surgical repair.*
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### Additional Images
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*Sagittal CTA following endovascular repair of the DD aneurysm shows a thoracic aortic stent graft <img src='img/arrows/BS.png'/> and exclusion of the DA <img src='img/arrows/WO.png'/>.*
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*Sagittal CTA shows a smooth, well-defined wide-based outpouching <img src='img/arrows/BO.png'/> from the aortic isthmus, consistent with a DD. The DD is located at the transition from the distal aortic arch to the descending aorta.*
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*Sagittal CTA shows a small bulge with gentle obtuse angles at the aortic wall, which is typical for DD <img src='img/arrows/WO.png'/>. The proximity of the DD to the main pulmonary artery <img src='img/arrows/BO.png'/> reflects that it is a remnant of the ductus arteriosus that connected the pulmonary artery to the aortic arch in utero.*
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*Sagittal CTA demonstrates an atypical DD, which forms acute angles with the aortic wall. However, the smooth, uninterrupted margin with the aortic wall <img src='img/arrows/BO.png'/> is consistent with this benign diagnosis.*
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*Axial CECT in the same patient shows the atypical DD <img src='img/arrows/WS.png'/>. In a setting of trauma, the lack of periaortic or mediastinal hematoma and the absence of an intimal flap aid in differentiating this from aortic pseudoaneurysm.*
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*Sagittal CTA in the same patient shows the outpouching from the anteromedial wall of aortic isthmus, which is consistent with a thrombosed ductus DA <img src='img/arrows/WS.png'/>. Although such aneurysms are rare, they can occur in older adult hypertensive patients with an atherosclerotic aorta.*
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*Candy cane view of the thoracic aorta shows a small DD <img src='img/arrows/CC.png'/> just distal to aortic isthmus. Note postoperative replacement of ascending aorta <img src='img/arrows/WS.png'/> for type A aortic dissection.*
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*Oblique sagittal CTA of the thoracic aorta shows type B aortic dissection <img src='img/arrows/CS.png'/> with incidental note made of the DD <img src='img/arrows/WS.png'/> arising from a false lumen.*
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*VRT of the thoracic aorta shows type B aortic dissection <img src='img/arrows/CS.png'/> with incidental note made of the DD <img src='img/arrows/WS.png'/> arising from a false lumen.*
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